Clinical Pre-Authorisation Consultant

Together with our client we are recruiting for a Clinical Pre-Authorisation Consultant (Call Centre) in Pretoria. The Candidate must be a registered nurse with SANC and have at least two years’ experience in the private healthcare sector. Previous experience working at a Medical Aid Scheme would be an advantage.

Duties and Responsibilities

• Receive applications for all services which require pre-authorisation.
• Handling of telephonic authorisations, hospital, radiology and specialist referrals on the pre-authorisation call centre.
• Capture clinical information and verify the information, including the applicable ICD-10 and item codes.
• Confirm membership status & available benefits on the system before authorisation can be granted.
• Validate and evaluate special pre-authorisation requests.
• Ensure that the correct codes are used before benefits are approved.
• Clinical interpretation and analysis of medical reports and/or doctor’s motivation.
• Provide correct applicable information in respect of scheme rules, benefits & approvals in respect of all services requiring to patients and service providers.
• Approve benefits accurately according to the benefits per benefit option and strictly according to the protocols to reduce the Scheme’s risk in respect of benefits.
• Accurate and complete capturing of all relevant information as well as approved documents on the appropriate operational systems.
• Deliver a high-quality service to the members and service providers.
• Keep abreast of amendments to scheme rules, benefit options, legislation, protocols, processes and systems

Job requirements

• Matric
• A completed degree/diploma as a registered nurse and must be registered with SANC.
• Two year’s clinical experience in a private hospital after Registration.
• Case management experience 
• Comprehensive knowledge of the Medical Schemes Act.
• Sound knowledge of CPT-4 & ICD-10 codes RPL.

Must possess the following skills:

• Technical and professional knowledge and skills;
• Managing work;
• Customer focus;
• Good verbal and written English communication skills as well as proficiency in understanding Afrikaans spoken and written communication;
• Computer literate.
• Must work well with people, and be able to handle conflict situations

Salary

• R 27 000 – R 33 000 Cost to Company (depending on experience)

Benefits

• Pension Fund
• 13th cheque
• Medical Aid

If you meet the above-mentioned requirements please send your CV, Qualifications, and SANC registration to recruit@medicalresources.co.za with REF: Clinical Pre-Authorisation Consultant